kartik s. jhaveri , md frcpc director, abdominal …...kartik s. jhaveri , md frcpc director,...
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Kartik S. Jhaveri , MD FRCPC
Director, Abdominal MRI
Director, CME Program
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CHOLANGIOCARCINOMA
Adenocarcinoma(mostly) arising from bile duct
epithelium -Liver to Ampulla of Vater
Diverse range of Growth patterns, Location and
Imaging appearances
Diagnostic and Therapeutic Challenges
Rising incidence over the last 3 decades
10-15% of hepatic primary malignancies
Relevance to Liver Transplant Elligibility
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OVERVIEW
DIAGNOSIS STAGING
MRI Protocol Pointers
Classification/Patterns
Surveillance - High Risk
Mimics
Staging Systems
Resectability
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Coronal T2 Axial In/Out phase
Axial Diffusion:
Axial 3D T1
Axial T2
CCA - MR PROTOCOL Radial MRCP
3D T2 MRCP Coronal 3D T1 4
CLASSIFICATION
Location Growth Pattern &
Morphology
ANATOMICAL INFO RISK FACTORS
BIOLOGICAL BEHAVIOUR
PROGNOSIS
ICC
ECC
MASS FORMING
PERIDUCTAL INFILTRATING
INTRADUCTAL
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Mass-Forming Periductal-Infiltrating Intraductal
CLASSIFICATION
CCA MIMICS
CRC Met
HCC
AIP/IgG4
Mirizzi
PSC
Portal Biliopathy
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Mass-Forming Periductal-Infiltrating Intraductal
• Lymphoma
• Mets
• Cast/blood
STAGING-IMPLICATIONS
• Surgery- Resection (or Transplantation) is the “only
effective treatment”.
• 5-year survival - Surgery ~ 10-30%
- No Surgery ~ 0%(Median 6m)
• Surgical Morbidity (>25%) & Mortality (>5%) is HIGH
•Accurate Staging is Critical !
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STAGING SYSTEMS
Bismuth-Corlette ( Perihilar)
TNM
Blumgart(MSKCC)
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STAGING – BISMUTH-CORLETTE
• Type I
CHD within 2cm of Confluence
• Type II
CHD involving both main RHD & LHD
• Type IIIa
Biliary Confluence and Secondary RHD radicle
• Type IIIb
Biliary Confluence and secondary LHD radicle
• Type IV
Bilobar Intrahepatic ducts involves secondary and tertiary radicles
INCOMPLETE SCHEMA AS NO ACCOUNT OF
VASCULAR INVASION ,NODAL STATUS AND
METASTASES
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STAGING-TNM
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AJCC 7th ed
• Pathology Criteria
• Post Op Staging System
• Survival Prediction
• Doesnot Correlate well with Resectability
STAGING- BLUMGART CLASSIFICATION
T1 = Biliary Confluence +/- unilateral extent to
2nd order ducts
T2 = T1 with ipsilateral portal infiltration +/-
ipsilateral lobar atrophy
T3 = Biliary confluence +
Bilateral extent to 2nd order ducts OR
Unilateral extent to 2nd order ducts with
Contralateral portal vein infiltration /
Lobar atrophy / bilateral or main portal vein
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Jarnagin . Ann Surg 1998
Matsuo JACS 2012 Best correlation Resectability(86% Acc)
Modified J-B Classification
Original Jarnagin-Blumgart (MSKCC)
Not useful Predicting Survival
13 Ding et al. World Journal of Surgical Oncology (2015) 13:99
RESECTABILITY
- Longitudinal and Radial Tumor Spread
- Vascular Involvement
- Lymph Node
- Distant Metastases
- Liver Volume
- Other Co-Existent Diseases
Biliary, Arterial and Portal Vein Anomalies
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STAGING- BLUMGART CLASSIFICATION
T1 = Biliary Confluence +/- unilateral extent to
2nd order ducts
T2 = T1 with ipsilateral portal infiltration +/-
ipsilateral lobar atrophy
T3 = Biliary confluence +
Bilateral extent to 2nd order ducts OR
Unilateral extent to 2nd order ducts with
Contralateral portal vein infiltration /
Lobar atrophy / bilateral or main portal vein
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Jarnagin . Ann Surg 1998
Matsuo JACS 2012 Best correlation Resectability(86% Acc)
Q
Is This Tumor Resectable?
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Vasc encase CASE
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CASE
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Surveillance of High-Risk Groups
Primary Sclerosing Cholangitis
Caroli’s Disease
Choledochal Cyst
Fluke Infestations-Clonorchis
Recurrent Pyogenic Cholangitis
Hepatolithiasis
5-15 %
7 %
5 %
PREDISPOSING DISEASE LIFETIME RISK
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PSC
1% Annual Incidence
Detection of CCA in PSC on single exam remains problematic
Serial MR + Tumour Markers (CA 19-9) increases yield
Charatcharoenwitthaya P et al. Utility of serum tumor markers, imaging, and biliary cytology for
detecting cholangiocarcinoma in primary sclerosing cholangitis.. Hepatology. 2008. 48 (4):1106
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PSC-CCA
JULY 2006 JAN 2007
Warning Signs On MR Imaging
•Short Interval Appearance / New area of Biliary Dilatation
•Unequal Regional/Segmental Biliary Dilatation
•Subtle /New Parenchymal Lesion adjacent to Bile ducts
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PSC-CCA
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PSC-CCA
8 MONTHS LATER
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Choledochal Cyst + CCA
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JULY 2008 SEP 2010
SUMMARY
MRI :Diagnosis, Staging & Surveillance
High Quality Imaging Key
Be Aware of Mimics.
Preop Staging/Resectability is Critical
Blumgart(MSKCC) system
CCA in PSC – Challenging
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